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Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism
  1. David Jiménez1,
  2. Drahomir Aujesky2,
  3. Lisa Moores3,
  4. Vicente Gómez1,
  5. David Martí4,
  6. Sem Briongos4,
  7. Manuel Monreal5,
  8. Vivencio Barrios4,
  9. Stavros Konstantinides6,
  10. Roger D Yusen7
  1. 1Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Madrid, Spain
  2. 2Division of General Internal Medicine, University of Lausanne, Lausanne, Switzerland
  3. 3F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
  4. 4Cardiology Department, Ramón y Cajal Hospital, Madrid, Spain
  5. 5Medicine Department, Germans Trias I Pujol Hospital, Badalona, Spain
  6. 6Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
  7. 7Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St Louis, Missouri, USA
  1. Correspondence to Dr David Jiménez Castro, Respiratory Department, Ramón y Cajal Hospital, IRYCIS, 28034 Madrid, Spain; djc_69_98{at}


Background In haemodynamically stable patients with acute symptomatic pulmonary embolism (PE), studies have not evaluated the usefulness of combining the measurement of cardiac troponin, transthoracic echocardiogram (TTE), and lower extremity complete compression ultrasound (CCUS) testing for predicting the risk of PE-related death.

Methods The study assessed the ability of three diagnostic tests (cardiac troponin I (cTnI), echocardiogram, and CCUS) to prognosticate the primary outcome of PE-related mortality during 30 days of follow-up after a diagnosis of PE by objective testing.

Results Of 591 normotensive patients diagnosed with PE, the primary outcome occurred in 37 patients (6.3%; 95% CI 4.3% to 8.2%). Patients with right ventricular dysfunction (RVD) by TTE and concomitant deep vein thrombosis (DVT) by CCUS had a PE-related mortality of 19.6%, compared with 17.1% of patients with elevated cTnI and concomitant DVT and 15.2% of patients with elevated cTnI and RVD. The use of any two-test strategy had a higher specificity and positive predictive value compared with the use of any test by itself. A combined three-test strategy did not further improve prognostication. For a subgroup analysis of high-risk patients, according to the pulmonary embolism severity index (classes IV and V), positive predictive values of the two-test strategies for PE-related mortality were 25.0%, 24.4% and 20.7%, respectively.

Conclusions In haemodynamically stable patients with acute symptomatic PE, a combination of echocardiography (or troponin testing) and CCUS improved prognostication compared with the use of any test by itself for the identification of those at high risk of PE-related death.

  • Echocardiography
  • lower limb ultrasound testing
  • prognosis
  • pulmonary embolism
  • troponin

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  • See Editorial, p 2

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  • Funding This study was supported by a FIS (080200) and a SEPAR (2008) grant.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Ramon y Cajal Hospital, Madrid, Spain.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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